Depression screening needed when patients experience sudden vision loss
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I did not serve as a physician in the military.
When entering medical school at the University of Minnesota in 1969 at the height of the Vietnam War, I received a Berry Plan medical training deferment. This allowed me to complete 4 years of medical school, a year of internship, 3 years of ophthalmology residency and 2 years of fellowship training without being called to active service. In exchange for the medical training deferment, I committed to 2 years of active military service upon completion of my medical training. I finished my medical training 10 years later in 1978, and at that time, the military had an excess of physicians and no need for me as an ophthalmologist. I therefore never experienced firsthand the extraordinary challenges of preserving and restoring vision in a war environment. These challenges are well described in the accompanying cover story.
It is heartbreaking to learn that modern warfare is generating evermore vision-threatening injuries. It is clear to me that blinding an enemy is an effective way to remove them from active combat while also placing a meaningful burden on their country of origin. According to an article published in 2021 in Military Medical Research, the 2% incidence of eye-related injuries reported for American soldiers in World War II increased to 13% in Operation Desert Storm.
While I never practiced in a military war zone, from 1980 to 1989, I served as chief of ophthalmology for the Minneapolis VA Health Care System. One of our major duties was to help rehabilitate the thousands of veterans who had suffered war-related eye injuries in prior conflicts. Our eye care was multifactorial, including optical, medical and surgical interventions as well as low vision aids and occupational therapy. Our team was well trained and equipped to manage the eye care needs of the veterans who had put themselves in harm’s way serving their country. But my team and I were less well prepared to manage the psychological impact of significant vision loss, especially when sudden and in a young adult with previously normal visual function.
Young adults with sudden vision loss are five times more likely to suffer clinical depression than those who are older and lose their vision slowly. Gallup polls have suggested that the top three fears for an American citizen are death, cancer and blindness — and not necessarily in that order.
Severe and sudden vision loss must be grieved. The classical stages of the grieving process are denial, anger, bargaining, depression and finally acceptance. Nearly every patient with sudden traumatic vision loss will experience depression after their injury, and for 25% to 40%, it will be permanent. It is important for we physicians to appreciate this fact, recognize the symptoms and signs of depression, and guide patients in need to appropriate professional support and care.
A useful screening tool for depression is the PHQ-9 questionnaire. There are nine questions scored as not at all (0), several days (1), more than half the days (2) or nearly every day (3). A total score of 0 to 4 is considered normal, 5 to 9 suggestive of mild depression, 10 to 14 moderate depression, 15 to 19 moderately severe depression, and 20 to 27 severe depression. Suicide risk becomes meaningful for patients with moderately severe to severe depression scores. This questionnaire can be found on the internet and copied for personal or practice use. My internist screens all patients at every visit with this questionnaire. Briefly, the questions query for lack of interest in daily affairs, feelings of depression, sleep disturbances, low energy, eating disturbances, self-loathing, poor concentration, slow movement or speech, and the impulse to hurt or kill oneself.
Of interest, many of we ophthalmologists, according to some studies, suffer from at least mild depression, so this is a test worth taking by each of us and any concerning family members, friends or patients. It can be awkward recommending professional mental health care to our patients, but it helps to know that those with significant vision loss, especially when sudden and in a young adult, need our help and encouragement to seek appropriate support and care.
- Reference:
- Hussain SF, et al. Mil Med Res. 2021;doi:10.1186/s40779-021-00334-3.
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